Headache Education - A“Case” for a Better Way!
R. Allan Purdy MD, FRCPC
Professor of Medicine (Neurology)
Dalhousie University, Halifax, CanadaOverview• Traditionally, doctors have been taught tolearn medicine by:– Lectures and laboratory work
– Which emphasize certain topics or ideas.

• Any thoughtful clinical teacher knows thebest laboratory is the patient and their caseis the best way to teach clinical medicine.

Case Based Learning• PBL or problem based learning, is a popularteaching methods in medical schools today…
In headache PBL has been studied in small
groups and on-line, with some success.

• CBL or case based learning is a majorteaching method in CME and is playing amajor role in headache teaching worldwide.

Tuesday Morning Lectures

The Learning Triangle
Teacher

SubjectStudentCase Can Be „Simple‟....
• Medical Student with“migraine” preceded bythree auras:– Visual blurring x 20 min– Numbness right face,
tongue and arm x 20 min– Visual spots times 20min• Followed by throbbing
headache either side..
• Normal examinationand on OCP

Questions on Case• What is prolonged aura?
• Does she have prolonged aura?
• Should she be on the OCP?
• Should she take a triptan?
• Are triptans safe?

The “Case”….
• The case is the international currency ofcommunication that unites learners of
medicine worldwide• When problems arise in the casecontext, the learning is more relevant
and knowledge sticks with the learner...

Typical Cases….
„Over a period of time, each patient noticed that the attacks wereappearing more frequently and that the response to the same
dosage became less dramatic. Each patient gradually began toincrease the dosage of the medicament, some on the advise of thephysician, others without his knowledge. With differences in time,each patient arrived at the same end-point, namely daily episodesof migraine and daily intake of ergotamine.‟….
Chronic migraine and medication-overuse
headache through the ages. Boes CJ, Capobianco
DJ. Cephalalgia. 2005 May;25(5):378-90.

The Author of This Report..
Arnold P. Friedman
Neurologist andHeadache Specialist
In 1945 founded the theHeadache Unit at Montefiore
Hospital in NYC – the first
specialized clinic in the world.
Friedman AP, Brazil P, vonStorch TJC. Ergotamine
tolerance in patients withmigraine. JAMA, 1955;157:881-4.

Clinical Cases• Cases have served the test of time asa most important way to learn medicine
and convey knowledge among peers.
• In age of evidence based medicine(EBM), it may seem odd to use cases
to teach complex ideas and concepts..

The Idea Is Not New…
“In what is called thenatural method ofteaching, the student
begins with the patient,continues with thepatient, and ends hisstudies with the patient,using books and lectures
as tools, as means to anend”.
Sir William Osler, The Hospital as a College (1928)

Not Knew At All!
“Probably in the not far distantfuture we will crawl out of ourold methods of education as asnake sheds its skin, andreorganize a new plan.”Charles Mayo, 1927

Special thanks to D. Capobianco MD, Mayo Clinic, JacksonvilleLectures and Laboratory• Lectures and laboratory study are still
important for many reasons…
• But doctors study cases and what theylearn stays with them..
Lectures are best used for thetransference of condensed knowledge
about the important aspects of a case ortopic..

Use of Case Knowledge• Condensed knowledge is learned byexpert clinicians over many years andstays with them; like other procedural
memories this accumulates.
• When presented in the right context, aspart of a case, such knowledge isinvaluable to the learner.

The Use of Science…
• Science would not advance withoutlaboratory work or formal scientificmethods• Each case is an experiment andrequires individual consideration tounderstand the relevance of the case incontext to broader knowledge base….

Clinical Knowledge• Acquisition of clinical knowledge depends on
texts and other standard methods; in time
pattern recognition or a heuristics occurs.
• If we have seen something before we are
more likely to recognize it again!
• Experience plays major role cases: Careful
not to anchor approach on the last caseseen or our best or worst experiences.
• Combined with EBM, may bring the bestresults.

Clinical Knowledge

TimeReality of Diagnosis…
• Headache assessment is a predominantly
qualitative diagnostic experience, mainly
based on a history.
Must see many patients with migraine tounderstand the full spectrum, but few cases of
SUNCT to remember this rare diagnosis.

• In secondary headache disorders, a broadclinical database is needed to, so we employ
more imaging and tests to diagnosis.

Continuing Medical Education• The traditional didactic learning format
predominates in CME today.
• A typical CME session consists of an expert
lecturer delivering information to a group ofphysicians in a top down fashion….

After D. Davis MD. University of Toronto CMEFailure of lecture method…
• Knowledge relayed is not delivered in a waythat can be applied to practice.
• Physicians have to translate information fromexperts and find ways to apply in practicesituations on their own.
• Given the conditions most physicians face intheir practice, this does not happen andlearning fails to occur.

Case Based Learning• PBL and CBL draws their theoreticalfoundation from cognitive psychology• PBL approach has the following effects
on those who participate……..
Medical Education Unit, Dalhousie

Linking Knowledge…
• Learners use past knowledge andexperience to seek new informationrelated to the problem at hand.
• Knowledge past and present isrestructured to fit the problem. All
knowledge is structured in memory.
Medical Education Unit, Dalhousie

PBL & Adult Education Theory• The problem and its resolution cues
learner when similar problems arise inpractice.
• Learners tend to be more internallymotivated to learn when the learning
can be seen to be relevant to what theyneed to know.
Medical Education Unit, Dalhousie

Time to Process…
• PBL with its presentation of problems
is believed to result in increased
learner motivation• Increases the time spent processing
and storing information in memory
ready for retrieval when needed.
Medical Education Unit, Dalhousie

Adult Education Principles.
• Needs Assessment: motivated to learn
when their learning needs are met.
• Relevance: motivated to learn when focus oflearning is life situations & not topics.
• Experience Based: motivated to learn whencontext of learning is their experience.
• Self-Directed: are more motivated to learn
when they direct & evaluate their learning.

Role of Educator• The role of the educator is to facilitate
the learning rather than transmit
knowledge and evaluate learners basedon their ability to regurgitate it..

Medical Education Unit, Dalhousie

Clinical Reasoning Process• Is the foundation of problem solving
and decision-making in medicine.
• Medical educators maintain that theclinical reasoning process ischaracterized by specific behaviours.
• These behaviours can be learned andevaluated…..
Medical Education Unit, Dalhousie

Process Behaviours• Hypothesis generation• Inquiry strategy and clinical skills• Problem formulation• Diagnostic and therapeutic decisions• Clinical reasoning process forms basisfor the PBL/CBL methodology.
Medical Education Unit, Dalhousie

Medical Knowledge Transfer!
“In a perfect world, health care information
would flow in a linear fashion. In reality,
the flow of information from one level toanother (eg., from researcher to policy
maker to clinician) is disorderly...and(even) chaotic.”
Battista et al, Disseminating
Research/Changing Practice, 1994

PBL in CME• The implementation of PBL/CBL in CME
is still its infancy• Educators believe that PBL in CME has
potential to become an effective
learning format for physicians.

After D. Davis MD. University of Toronto CMEWhat is the Evidence?
• What's the evidence that these methods
produce different or better physicians?
• Several reasons for such disbelief….
• Confounding variables, education is contamination• Educational research methods are qualitative and don‟tanswer essential quantitative questions….
• We know, as clinician-scientists, that qualitative researchis suspect….

Evidence-Based Education, Dave Davis, MD, FCFP, University of Toronto

Analysis of covariance between groups on the post-test, using thepre-test result as covariate, showed significantly:• Greater knowledge in the PBL group. Mean post-test scores also
were significantly higher for the PBL group.
• The PBL group's satisfaction with several programmedimensions was significantly higher than that of the lecture group.

Evaluation of a CME problem-based learning internet discussion.
Sargeant JM, Purdy RA, et al. Acad Med. 2000 Oct;75(10 Suppl):S50-2

The Dissonance…
• On one hand, the majority of what goes by
the name of CME in medical schools,
professional societies are didactic courses…
• On the other hand, the research is clear thatthese methods of CME do not changephysician performance and/or health careoutcomes
After D. Davis MD. University of Toronto CMECanadian Headache Society• Migraine Guidelines
Course for family
doctors andpharmacists...
• Communications
Skills Workshops for
Neurologists...

The Case...almost forgot!
• Aura is reversible focal neurologicalsymptoms that usually develop gradually over
5-20 minutes and last for less than 60
minutes and prolonged aura was >60m inprior IHS (1988)• She should probably be off OCP• Her triptan “stops” aura but not headache….
• Triptans are safe, generally…..

THE “Learning Triangle”!
Interested Teacher

Interesting CASE!

Interested Student

Why does it matter?
• Simply put, everything we do and every
interaction in clinical medicine is picked
upon by the learner - teachers havetremendous influence for good........
• It is never a disease or a test for that matterthat sticks in the learners head...it is thememory of being „taught‟......and how it wasdone in the context of a „patient!‟
Purdy, RA. Personal communication, 2010

In Conclusion…
• Headache is a common disorder with major
medical and social consequences for thepatient and society…
• Important to pursue teaching strategies thatmaximize the learner‟s ability to gain relevant
knowledge in the most memorable way.
• CBL is here to stay in headache education!
• Cases are a better way, but not the only, tolearn headache medicine.....

This lecture is over....thanks!